Rest Not Needed After Elbow Injection

Action Points

Explain to interested patients that this study suggests that resumption of normal activities is acceptable after a glucocorticoid injection to the elbow.

Remind them that this is not the case with knee injections, where studies have shown that a period of rest leads to a better outcome.

Patients with elbow synovitis who receive intra-articular glucocorticoid injections should not be told to immobilize or rest the joint in the immediate post-procedure period, Swedish researchers determined.

Elbow pain, function, and mobility were no different in patients who were randomized to 48 hours of immobilization than in those who resumed normal activities, according to Tomas Weitoft, MD, PhD, of Uppsala University and Catarina Forsberg, MSc, of Falu Hospital in Falun, Sweden.

At six months, pain scores were similar in the rest and activity groups, having fallen by 17 and 16 points, respectively. Function scores also were similar, having improved by 31 and 29 points, respectively, the researchers wrote in the May issue of Arthritis Care & Research.

"For decades, intra-articular glucocorticoid injections have been a cornerstone in the treatment of arthritis. Despite this large amount of clinical experience, there is still no consensus about optimal injection routines," the researchers wrote.

One point of uncertainty has been what recommendations to give patients after the injection.

Studies have shown that a 24- to 48-hour period of rest after intra-articular injections for knee synovitis improved outcomes, while a similar period of immobilization after wrist injection had no benefit.

This discrepancy may relate to notable differences in joint size, anatomy, and weight bearing.

The elbow shares features with both wrist and knee. Like the wrist, it is not a weight-bearing joint, but the structure and range of movement are more similar to those of the knee.

Patients were given injections of 20 mg triamcinolone hexacetonide, and then randomized to 48 hours of immobilization, using a triangular sling, or to normal activity with no restrictions.

Pain and function of the joint were assessed on the Patient Rated Elbow Evaluation questionnaire, which includes five questions on pain and 11 on functional impairment.

Median age of participants was 64 and most were women.

One week after the injections, pain scores had improved by 14 points in the rest group and 16 points in the active group, while function had improved by 26 and 27 points in the two groups, respectively.

At six months the change in range of motion was 15 degrees in the active group and 18 degrees in the rest group, which was nota significant difference.

Because there were no statistically significant differences between the groups, the authors reported that there was no benefit to immobilization.

They also noted that there were more relapses during the observation period in the immobilization group (13 versus eight).

"Because neither wrists nor elbows respond with a better outcome after postinjection rest, we conclude that patients with intra-articular glucocorticoid treatment of joints of the upper extremity should not be given advice to rest after the injection," the researchers said.

The study also confirmed that the treatment is very effective for pain, function, and mobility.

The authors noted that they had difficulties in recruiting patients for the study, possibly because treatment with biologic therapies may have reduced the use of intra-articular injections.

Also, patients who traveled by car for treatment could have been unwilling to participate because of difficulties driving if they were randomized to immobilization.

"To our knowledge, this is the largest elbow injection study to date, but an even larger patient group would have been ideal," they conceded.

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